THE COMMONWEALTH OF MASSACHUSETTS

Division of Banks

1000 Washington Street, 10th Floor, Boston, MA 02118

TEL: 617-956-1500 | TDD: 617-956-1577 | FAX: 617-956-1599

MASS.GOV/DOB

Criminal Offender Record Information (CORI) Instructions

Attached is the CORI Request Form which must be completed in its entirety. Additionally, the applicant’s identity must be verified with a government issued photographic form of identification and the applicant’s signature appearing on the CORI request form must be authenticated by a notary. Please be sure to submit a copy of a government issued photographic form of identification with the CORI request form. CORI request forms submitted without this information, or which have not been notarized, will not be processed.

Criminal Offender Record Information (CORI)

Acknowledgement Form

The Division of Banks is registered under the provisions of Massachusetts General Laws chapter 6, section 172 to receive CORI for the purpose of screening the following individuals:

Officers of, and applicants for, bank and credit union charters;

  • Applicants for licenses to engage in the business of a check casher, check seller, debt collector, foreign transmittal agency, insurance premium finance company, mortgage broker, mortgage lender, motor vehicle sales finance company, retail installment sales finance company, small loan company; and
  • Applicants for a license to engage in the activity of a mortgage loan originator for which the Division also has been certified to access non-conviction criminal data.

As an above-described bank officer or license applicant, I understand that a CORI check will besubmitted for my personal information to the Department of Criminal Justice Information Services (DCJIS). I hereby acknowledge and providepermission to the Division of Banks to submit a CORI check for my information to the DCJIS. This authorization is valid for one year from the date of my signature. I may withdraw this authorization at any time by providing the Division of Banks with written notice of my intent to withdraw consent to a CORI check.

I also understand that the Division of Banks may conduct subsequent CORI checks within one year of the date this Form was signed by meprovided, however, that Division of Banks must first provide me with written notice of this check.

By signing below, I provide my consent to a CORI check and affirm that the information provided on Page 2 of this Acknowledgement Form is true and accurate.

______

Signature of CORI SubjectDate

On this day of , 20__, before me, the undersigned notary public, personally appeared ______(name of document signer), proved to me through satisfactory evidence of identification, which were ______, to be the person whose name is signed on the preceding or attached document, and acknowledged to me that (he) (she) signed it voluntarily for its stated purpose.

Notary Public

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SUBJECT INFORMATION
Please complete this section using the information of the person whose CORI you are requesting.
The fields marked with an asterisk (*) are required fields.

*First Name: ______Middle Initial: ______

*Last Name: ______Suffix (Jr., Sr., etc.): ______

Former Last Name 1: ______

Former Last Name 2: ______

Former Last Name 3: ______

Former Last Name 4: ______

*Date of Birth (MM/DD/YYYY): ______Place of Birth: ______

*Last SIX digits of Social Security Number: ______‐‐ ______☐ No Social Security Number

Sex: ______Height: _____ ft. _____ in. Eye Color: ______Race: ______

Driver’s License or ID Number: ______State of Issue: ______

Father’s Full Name: ______

Mother’s Full Name: ______

Current Address

*Street Address: ______

Apt. # or Suite: ______*City: ______*State: ______*Zip:

******* SUBJECT VERIFICATION – FOR DIVISION OF BANKS USE ONLY *******

The above information was verified by reviewing the following form(s) of government‐issued identification:

Verified by:

______

Print Name of Verifying Employee

______

Signature of Verifying EmployeeDate

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